1-12 days
Foodborne:
12-72 hours
range,
2 hours – 8 days
Cutaneous
Anthrax
Botulism
Usually none.
If foodborne,
possibly nausea,
vomiting,
abdominal cramps
or diarrhea.
Painless or
pruritic papule
Non-specific:
fever, malaise,
cough, dyspnea,
headache, vomiting,
abdominal and
chest pain.
Diagnostic Samples
Swab of lesion,
skin biopsy, blood.
Nasal swab
(if obtained
immediately following
inhaled exposure),
serum, gastric
aspirate, stool,
food sample
when indicated.
Papule evolves into a
vesicular or ulcerative lesion,
then forms a black eschar
after 3-7 days.
Afebrile, ptosis, diplopia,
dysarthria, dysphonia,
dysphagia, symmetrical
descending paresis or flaccid
paralysis. Generally normal
mental status. Progresses to
airway obstruction and
respiratory failure.
Widened mediastinum,
Blood, serum,
pleural effusion on chest x-ray. CSF, pleural or
Rapid onset of severe
ascitic fluids.
respiratory distress,
respiratory failure,
and shock.
Clinical Syndrome
Early Symptoms
Non-specific:
high fever, cough,
chills, dyspnea,
headache,
hemoptysis,
nausea, vomiting,
diarrhea.
Clinical Syndrome
Non-specific:
fever, malaise,
headache,
prostration, rigors,
vomiting, severe
backache.
Blood, tissue
Vesicular or
pustular fluid,
pharyngeal swab,
scab material,
serum.
Maculopapular, vesicular,
then pustular lesions all at
same developmental stage
in any one location.
Begins on face, mucous
membranes, hands and
forearms; may include
palms and soles.
Serum, sputum
Diagnostic Samples
In high doses, short
incubation and rapid
onset suggestive of
chemical agent.
Self-limited febrile illness
lasting 2 days to 2 weeks,
may present like atypical
pneumonia (Legionella).
Clinical Syndrome
Incubation Period
3-5 days;
range: 1-14 days
2-21 days;
Viral
hemorrhagic varies among
viruses
fevers
(Ebola,
arenavirus,
filoviruses)
Tularemia
Staphylo3-12 hours
coccal
for inhalation.
enterotoxin B Minutes to hours
for ingestion.
Disease
Fever, myalgias,
petechiae,
easy bleeding,
red itchy eyes,
hematemesis.
Non-specific:
fever, fatigue, chills,
cough, malaise,
body aches,
headache,
chest discomfort,
GI symptoms.
Short incubation
and rapid onset
suggestive of
chemical agent.
Inhalation:
Fever, chills,
headache, myalgias,
cough, nausea.
Early Symptoms
Febrile illness complicated
by easy bleeding,
petechiae, hypotension,
and shock.
Pneumonitis, ARDS, pleural
effusion, hemoptysis,
sepsis. Ocular lesions,
skin ulcers, oropharyngeal
or glandular
disease possible.
Ingestion:
nausea, vomiting, diarrhea
Inhalation:
Dyspnea, retrosternal pain
may develop
Clinical Syndrome
Serum, blood
Serum, urine,
blood, sputum,
pharyngeal washing,
fasting gastric
aspirate, other.
Ingestion:
stool, vomitus
Inhalation:
serum, urine
Diagnostic Samples
RECOGNIZING AND DIAGNOSING ILLNESSES POSSIBLY DUE TO BIOTERRORISM – Table 4
12 days;
range: 7-17 days
Smallpox
Fever, headache,
chills, heavy
sweats,
arthralgias.
Early Symptoms
Inhalation:
fever, weakness,
cough, hypothermia,
hypotension,
cardiac collapse.
10-40 days
Q fever
Ricin
18-24 hours
(toxin from
castor bean oil)
Incubation Period
Disease
Viral culture,
PCR, serology.
Gram stain, culture;
DFA or IHC staining
of secretions,
exudates or biopsy
specimens.
Specialized Labs:
Ag-ELISA, Ab-ELISA
serology.
Diagnostic Tests
Specialized labs:
PCR, viral culture,
electron or light
microscopy, serology.
Serology,
IHC staining
of tissue.
Serology,
Culture difficult.
Diagnostic Tests
Specialized labs:
Serology, DFA, PCR
Gram, Wright, or
Wayson stain; culture
Fulminant pneumonia,
Blood, sputum,
often with hemoptysis, rapid lymph node
progression of respiratory
aspirate, serum.
failure, septicemia and shock.
Presence of hemoptysis
may help distinguish from
inhalational anthrax.
Culture, serology, PCR
Viral culture,
serology, PCR
Blood, serum,
bone marrow,
tissue.
Diagnostic Samples Diagnostic Tests
Specialized labs:
Mouse bioassay
for toxin
Gram stain, culture of
lesion; blood culture
Specialized labs:
PCR, serology
Specialized labs:
IHC, serology,
DFA, PCR
Gram stain or Wright
stain; blood culture
Fever, headache, stiff neck,
Serum, CSF
nausea, vomiting, sore throat,
diarrhea lasting several days
often followed by prolonged
period of weakness and lethargy.
Central nervous system
symptoms may develop.
Systemic illness, may
become chronic with fever
and weight loss. May have
suppurative lesions.
Bone/joint lesions common.
RECOGNIZING AND DIAGNOSING ILLNESSES POSSIBLY DUE TO BIOTERRORISM – Table 3
1-6 days
Pneumonic
Plague
Fever (often
intermittent),
headache, chills,
heavy sweats,
arthralgias.
Non-specific:
Sudden onset of
malaise, fever, rigors,
severe headache,
photophobia,
myalgias of legs
and back.
Very variable,
5-60 days
Brucellosis
Equine
2-6 days,
Encephaltides Venezuelan
(Eastern,
Western,
5-15 days, others
Venezuelan)
Incubation Period
Disease
RECOGNIZING AND DIAGNOSING ILLNESSES POSSIBLY DUE TO BIOTERRORISM – Table 2
Inhalational:
12-80 hours
1-7 days
(possibly up to 60
days)
Incubation Period Early Symptoms
Inhalational
Anthrax
Disease
Diagnostic Tests
Healthcare providers should be alert to illness patterns and diagnostic
clues that might signal an act of bioterrorism (BT). The following
clinical and epidemiological clues are suggestive of a possible
BT event:
• A rapidly increasing disease incidence
• An unusual increase in the number of people seeking care,
especially with fever, respiratory, or gastrointestinal symptoms
• Any suspected or confirmed communicable disease that is not
endemic in New York (e.g., plague, anthrax, smallpox or viral
hemorrhagic fever)
• Any unusual age distributions or clustering of disease
(e.g., chickenpox or measles in adults)
• Simultaneous outbreaks in human and animal populations
• Any unusual temporal and/or geographic clustering of illness
(e.g., persons who attended the same public event)
Any unusual illness or disease clusters should be reported
immediately to your county health department.
PHONE NUMBERS
New York State Department of Health
Communicable Disease Control
518-473-4436
After hours: Duty Officer
1-866-881-2809
New York State Biodefense Laboratory
518-474-4177
New York City Department of Health and Mental Hygiene
Communicable Disease Program
212-788-9830
After hours: within Manhattan
212-764-7667 (212-POISONS)
outside Manhattan
1-800-222-1222
NYC Public Health Laboratories
212-447-1091
Your County Health Department
Consult phone book blue pages under
“County Offices”
RECOGNIZING AND DIAGNOSING ILLNESSES POSSIBLY DUE TO BIOTERRORISM – Table 1
RECOGNIZING BIOTERRORISM-RELATED ILLNESSES
Supportive care – analgesics, anticonvulsants
as needed.
Doxycycline plus streptomycin or rifampin.
Alternatives: ofloxacin plus rifampin; doxycycline
plus gentamicin; TMP/SMX plus gentamicin.
Supportive care – ventilation may be necessary.
Trivalent equine antitoxin (serotypes A,B,E –
available from CDC) should be administered
immediately following clinical diagnosis.
Ciprofloxacin; doxycycline
Combination therapy of ciprofloxacin or
doxycycline, plus one or two other antimicrobials
should be considered with inhalation anthrax.
PCN should be considered if strain
is susceptible.
TREATMENT
Supportive care.
Ribavirin may be effective for Lassa fever,
Congo-Crimean hemorrhagic fever, Rift Valley fever.
Standard precautions.
Standard. Contact precautions if lesions present.
Tularemia
Standard and contact precautions.
Viral
Hemorrhagic Airborne precautions, especially in late stages.
Fever
Venezuelan Standard precautions.
Equine
Encephalitis
Standard, contact and airborne precautions.
Q fever
Smallpox
Standard precautions.
Standard. Droplet precautions until on
Plague
(pneumonic) appropriate therapy for 72 hours. Contact
precautions if draining buboes present.
Botulism
Brucellosis
No
GL, GO=when entering the room
M=N-95 respirator
GL=when entering the room
GO=if likely contact with patient,equipment or environment
GL, GO=when entering the room
M=N-95 respirator
No
Yes
Negative pressure
No
Yes
Negative pressure
No
GL=when entering the room
Yes
GO=if likely contact with patient,equipment or environment Cohort if
M=surgical mask
necessary
GL=Gloves GO=Gowns M=Mask
Standard. Contact precautions for cutaneous and GL=when entering the room
No
gastrointestinal anthrax if diarrhea is not contained. GO=if likely contact with patient,equipment or environment
No
Standard precautions.
Anthrax
PRIVATE ROOM
PRECAUTION CATEGORY
*See other side for explanation
of each precaution
PERSONAL PROTECTIVE EQUIPMENT
Ribavirin may be effective for Lassa fever,
Congo-Crimean hemorrhagic fever,
Rift Valley fever.
Tetracycline; doxycycline; ciprofloxacin
None
Vaccination given within 3-4 days of exposure
can prevent or decrease the severity of disease.
None
Tetracycline; doxycycline (may delay but not
prevent illness).
Tetracycline; doxycycline;
ciprofloxacin
PROPHYLAXIS
None
Doxycycline plus streptomycin or rifampin
None
Ciprofloxacin or doxycycline, with or
without vaccination. If susceptible,
PCN or amoxicillin should be considered.
PROPHYLAXIS
AGENT
INFECTION CONTROL PRECAUTIONS FOR BIOLOGICAL AGENTS
Streptomycin; gentamicin. Alternative: ciprofloxacin
Viral Hemorrhagic Fevers
Supportive care.
Staphylococcal Enterotoxin B
Tularemia
Supportive care.
Cidofovir shown to be effective in vitro.
Supportive care. Treatment for pulmonary edema.
Gastric decontamination if toxin is ingested.
Tetracycline; doxycycline
Streptomycin; gentamicin.
Alternatives: doxycycline; tetracycline;
ciprofloxacin; and chloramphenicol.
TREATMENT
Smallpox
Ricin
Q-Fever
Pneumonic Plague
AGENT
TREATMENT AND PROPHYLAXIS - Table 2
Equine Encephalitides
(Eastern, Western,
Venezuelan)
Brucellosis
Botulism
Anthrax
Inhalation/Cutaneous
AGENT
TREATMENT AND PROPHYLAXIS - Table 1
INFECTION CONTROL PRECAUTIONS:
Standard Precautions: Standard precautions apply to blood, all
body fluids, secretions, nonintact skin, mucous membranes and
excretions, except sweat. Gloves and gowns should be used to prevent exposure to blood and other potentially infectious fluids. Mask
and eye protection or face shield should be used during procedures
or activities that are likely to generate splashes or sprays of blood,
body fluids, secretions or excretions. Appropriate hand hygiene is
always necessary.
Additional Precautions for the following:
Droplet Precautions: Private room or cohort patients with same
infectious agent. Use a mask if within 3 feet of a patient.
Contact Precautions: Private room or cohort patients with same
infectious agent. Use gloves when entering the room and a gown if
clothing is likely to have contact with patient, environmental surfaces
or patient care equipment.
In general, persons exposed to a biological agent need only to remove
clothing, if heavily contaminated, and use shampoo, soap, and water
on themselves (shower). The clothing should be bagged and laundered normally in hot water. No precautions for effluent water are
needed. Dilute bleach solutions should NEVER be used on people,
only environmental surfaces.
Rapid
Response
Card
Airborne Precautions: Requires a negative pressure isolation room
and appropriate respiratory protection such as the N95
respirator which has been fit-tested.
Reference: Garner JS, Hospital Infection Control Practices Advisory
Committee. Guidelines for Isolation Precautions in Hospitals.
Infection Control Hospital Epidemiology 1996;17:53-80.
DECONTAMINATION GUIDELINES:
State of New York • George E. Pataki, Governor
Department of Health • Antonia C. Novello, M.D., M.P.H., Dr. P.H., Commissioner
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